Brazilian State Leads Way in Saving Children

By JAMES BROOKE,

Published: May 14, 1993

MARACANAU, Brazil—
In the dim, smoke-stained interior of a sharecropper's shack, 1-year-old Maria sat quietly on the dirt floor, her infant spark dulled by diarrhea and malnutrition.

With seven other children to care for, Maria's mother, Antonia Souza Lima, explained that she could not afford the time -- an hour-and-a-half walk -- or the 40-cent bus fare to take her listless baby to the nearest medical post.

Fading quietly, Maria seemed destined to become one of the 250,000 Brazilian children who die every year before turning 5.

But in a new effort to cut the devastating infant mortality rate here, a community health worker recently started to walk weekly to the Lima household, bringing oral rehydration formula for Maria and hygiene advice for her mother, who has a television setbut no water filter.

With the new public health program, involving a low-cost army of health workers, Ceara state is showing Brazil that even in times of economic austerity infant mortality can be cut.

In four years, Ceara, one of the poorest of Brazil's northeastern states, cut its infant mortality rate by nearly one-third. The number of babies who died before reaching their first birthday was 39 per 1,000 live births in 1990, the last year a survey was conducted, down from 57 per 1,000 in 1987.

Increasingly, Brazilians are discussing their child mortality record, one of the worst in the Americas, and health planners from other northeastern states are flocking to Ceara to study its program,

While Brazil has a $450 billion economy -- roughly the same size as those of Russia and China -- health workers point out that economic statistics do not always measure human welfare.

Brazil scores poorly on infant mortality, the number of babies who die before their first birthday. Although its $2,920 per capita income is eight times that of China, Brazil has an infant mortality rate two and a half times China's -- of every 1,000 live births, 55 Brazilian babies die before their first birthday.

"With the 'economic miracle,' middle-class infant mortality vanished, but it has not been dislodged from the shantytowns, from the rural northeast," said Nancy Scheper-Hughes, an anthropology professor at the University of California at Berkeley, referring to Brazil's explosive economic growth under the military Governments of the 1960's and 1970's.

While Brazil's ruling army generals prided themselves on building the world's biggest dam and the world's longest bridge, they never showed enthusiasm for programs that cut infant mortality, like education for women, day-care centers and the promotion of breast-feeding.

After civilian rule returned in 1985, Government mismanagement, corruption and heavy indebtedness undermined efforts to improve health conditions. Typically, a Government effort in 1991 to duplicate Ceara's health plan nationally was derailed when scandal forced the Health Minister to resign.

"The minister came here to look at our program," said Tasso Jereissati, who started the program as Ceara's Governor. "I said this has to be a simple as possible -- someone from the community, walking on foot with a little backpack." Local Solutions Sought

The program, called Viva Crianca, or Long Live the Child, was started in 1987 by Mr. Jereissati, a Social Democrat whose party in elections the year before turned out a group of conservative, landowning politicians. Declaring child survival a state priority, Mr. Jereissati drew up the program with the help of local doctors. The first community health agents were drawn from 6,000 people who were given temporary work in the 1987 drought.

Today, with the central Government largely paralyzed as 19 political parties jockey for power, more and more Brazilians look for local solutions.

Once a month, the 7,240 workers in the Ceara health program enter the homes of four million people, the poor majority of a state where most people's incomes are less than $1 a day.

In six years the locally financed program has lifted Ceara from near the bottom to near the top of Brazil's 26 states in child-protection indicators like vaccinations, child visits to pediatricians and duration of breast-feeding. To help the children of working mothers, the number of community-run day-care centers has soared, from 8 in 1987 to 257 today.

The program is intended to reverse the centralization of health resources found in much of the third world. Costs 'Virtually Nothing'

"Instead of having sick citizens clog hospitals, we opted for prevention and family visits," said Ciro Gomes, Ceara's 35-year-old Governor, who since taking office two years ago has extended the program to all 182 towns in the state. "The health agent program costs virtually nothing -- $500,000 a month."

In recognition of this achievement, Unicef is bestowing on "the people and the state of Ceara" the 1993 Unicef Maurice Pate Award, a prize that honors child-protection efforts. For the first time in the award's 27-year history the award is going to South America.

In a country where newspapers frequently report on people dying while waiting in lines at Government-run hospitals, the idea of decentralized, preventive medicine has increasing appeal. After 12 years of economic stagnation, many people argue that Brazil's children cannot afford to wait for the benefits of a hypothetical future growth to trickle down.

Viva Crianca stipulates that health agents be picked from the communities where they live. They earn Brazil's minimum wage -- currently $55 a month. The state recently started to distribute bicycles and baby scales to some agents.

"A bicycle would help," said Maria de Fatima Goncalves as she showed Mrs. Lima how to produce oral rehydration formula from salt, sugar and clean water. "Some of the houses are far away."

Dressed in a white T-shirt and denim shorts, Miss Goncalves carried the bare necessities in a small backpack: soap, scissors, an ointment for burns, a fine comb for lice and a medicine for scabies. The 22-year-old is responsible for visiting each month 82 rural families who live within a four-mile radius of her house.

To many in Ceara, where Viva Crianca is enormously popular, the home visits and referrals are the greatest value. "I tell the agents they are my eyes and ears," said Pedro Correia, a hospital surgeon in Morada Nova, a town 150 miles south of here.

And for the peasants in Brazil's outback, the arrival of health care workers is a welcome novelty. Erismar Rodrigues de Lima, a neighbor of the Limas, listened intently to instructions on filtering drinking water.

"I am the first member of my family to ever receive prenatal care," said the 22-year-old woman, who is expecting a baby in June.

Photo: In Brazil, where 250,000 children die every year before turning 5, a family carried a child's coffin in Ceara. (Evandro Teixeira) Graph: "Infant Mortality: How Brazil Compares" shows child mortality and per capita income for selected countries in 1991. (Source: Unicef, World Bank Atlas) (pg. A8) Map of Brazil showing location of Ceara. (pg. A8)